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Colorectal Cancer: An Overview S. Maitra Colorectal Cancer Colon 2/3rd Equal in both sexes Rectum 1/3rd More common in men Lung Colorectal Prostate Men Breast Women Incidence & Mortality, Colorectal Cancer, England* Site ICD 10 No regd 1999 M W Crude Inc Rate/ Deaths 2000 Mortality/ 100,000 100,000 M W M W M W Colon C18 8822 9013 35.9 35.8 4814 4740 19.5 18 Rectal C19 & 20 6009 3970 24.5 16.8 2605 1895 10.5 7.5 Anus C21 255 382 *office of national statistics 1.0 1.5 78 104 0.3 0.4 And the problem is increasing…. •Ageing of the population < 45- very low risk 45 –55- 25/100,000 •Lifestyle Factors More meat , less vegetable Obesity Smoking > 75- 300/100,000 Risk of Colon Cancer by Family H/O 60 Relative Risk 50 45 55 65 75 40 30 20 65 10 45 0 4 3 2 1 Family History Category:1= No family H/O; 2= One first degree relative > 45 at diagnosis 3= One first degree relative < 45 at diagnosis 4= Two first degree relatives Other risk factors……… •Familial Adenomatous Polyposis(FAP) •Hereditary Non polyposis Colorectal Cancer (HNPCC) •Inflammatory Bowel Disease Clinical Presentation Early •PR Bleeding •Persistent change in bowel habits •Anaemia Usually progresses slowly from polyps over 10 yrs Late •Weight loss 20% arrive through A/E •Abdo pain •Abdo mass Diagnostic Methods Flexible sigmoidoscopy (can pick up 60% of tumours) Colonoscopy Double contrast barium enema Rigid sigmoidoscopy Newer Diagnostic Method Some evidence better than Barium enema Almost as accurate as Colonoscopy for larger Polyps(>10mm) only Potential complications (including perforation) similar to other procedures Alternative to Barium enema Useful in frail & elderly as initial screening Diagnostic Issues: Who to be tested? To pick up cancer /polyp at early stage. What is the Benefit : Risk Ratio? 1. Symptomatic patients 2. High Risk group (Surveillance) 3. General Population Screening 1. Symptomatic Patients (Urgent Referral Criteria)** Sign,Symptom or Combination Age threshold Rectal bleeding with new diarrhoea for 6 weeks Any age Definite palpable right abdo mass Any age Definite palpable rectal( not pelvic) mass Any age Rectal bleeding WITHOUT anal symptoms > 60 yrs* New diarrhoea WITHOUT rectal bleed for 6 weeks > 60 yr* IDA# ( Hb < 11 in men and < 10 in postmenopausal women) without obvious cause No age criterion *Maximum threshold. Local Network may elect lower values #IDA= Iron Deficiency Anaemia ** Department of health Which Test for Whom? 1.Rectal bleeding/ :Change in bowel habit (ie left sided symptoms) Flexi sigi (chance of missing cancer is 0.2%) 2.Right abdo pain IDA :- Colonoscopy if unsuccessful or frail/elderly Barium enema/ CT Colonography 3.Palpable abdo mass :- CT scan or CT Colonography 2. Surveillance* Disease Group Procedure First Screening Repeat 1-2 ; both< 1cm Colonoscopy None or at 5 yrs Stop after one negative 3-4; or at least 1> 1cm Colonoscopy Three years 3 yearly till two Negative >4 or > 2 with 1 at least >1 cm Colonoscopy One year Annually till out of this grp IBD Colonoscopy & Bx every 10cm 8yrs-pancolitis 2nd dec- 3yrly 15yrs- left sided 3rd dec- 2yrly >3rd - annually FAP Genetic test + OGD + Flexi Puberty Annually 2 FDR or 1 FDR < 45 yrs Colonoscopy 1st visit or 35- 40 yrs If initial Colonoscopy clear then at 55 Colon Adenoma * BSG Guidelines 3. Population Screening: NHS Colorectal Cancer Screening Programme Due to start from April 2006 35 million £ 8 training centers 650 new endoscopists FOBTsin men & women > 60 years if positive Colonoscopy Flexible Sigmoidoscopy as a pilot study in men > 50 FOBT (Faecal Occult Blood Test) Reduces Mortality ( 3 American & 2 European RCTs) Pre test dietary restriction for 3 days (Avoid red meat, horseradish, Vitamin C) High fibre diet advised Six guiac strips to be smeared two each 3 consecutive stool Any amount of blue in any one strip is positive ( Guainoic acid Guanicum blue Haemoglobin Treatment Dukes’ Stage Definition Frequency* 5year Survival* A Cancer localized within bowel wall 11% 83% B Cancer penetrating bowel wall 35% 64% C Cancer in lymph nodes 26% 38% D Distant metastases 29% 3% Duke A, BDuke CDuke D- Curative surgery attempted Surgery + Adjuvant Chemo Surgery + liver resection (in 8%) or Palliative chemo/radiotherapy or stent *St Vincent Hospital Dublin Survival Country Relative survival (%) 1 year after diagnosis* Colon M Rectum W M W England 64.9 64.2 70.5 71.8 Scotland 65.7 65.7 71.3 71.3 Wales 53.5 52.5 64.5 63.9 Europe 69.2 69.8 73.7 75.2 *1990- 1994 data from International agency for research on Cancer Welcome to the Colossal Colon Online Tour. In an effort to educate the public on colorectal cancer prevention, early detection and treatment, the Colossal Colon Tour will visit 20 cities in the U.S. from February 2003 to November 2003. The main attraction of the Tour is the Colossal Colon, along with nine interactive educational stations. Missed the Tour when it came through your city? Did the Tour not visit your hometown? Had so much fun at the Tour that you want to see it again? Click on the entrance below to visit our ten stations -from prevention to treatment! Click here to take a video tour of the Colossal Colon The Colossal Colon Tour is brought to you by the Cancer Research and Prevention Foundation (formerly the Cancer Research Foundation of America) and made possible by Roche Pharmaceut home | the colossal colon tour | frequently asked questions get involved | online tour | press | take the pledge national tour partners and sponsors © 2003 Cancer Research and Prevention Foundation